You can read the article in Hebrew here, thanks to Idan Melamed!
Up until now we’ve been focusing on infant responsiveness which is primarily linked to crying-it-out, or sleep, strategies. However, we’re going to take a turn today and focus instead on the concept of routines or schedules. Most of you are adamant advocates for the schedule. Some of you are more strict than others, but you nearly all say that parents should instill a “routine” (really you mean “schedule”) starting at day one, most claiming that researchers and doctors state that children do better when they know what’s coming. Quite expectedly, it’s not that simple.
First, most work on schedules (and the lack thereof) have been done with parents who have shift-work, meaning that there can be immense interruption in the child’s schedule, but even within these studies, there are factors that both mitigate the effects, such as having a second parent at home while one is at work to take care of the child, and that may explain the relationship outside of the nonstandard schedule, such as increased parental stress. Second, some of the other work I’ve seen cited has to do with children with Autism Spectrum Disorders who are known to require structure and routines in order to thrive. Third, most of this work is also done with older children, preschool age and above, limiting the generalizability to newborns, infants, and toddlers. Finally, there’s also evidence that schedules that don’t leave room for flexibility and free time don’t aid a child’s socioemotional development. Thus, the idea that our newborns require a schedule is not quite as clear as you would like parents to believe. I will say that there is nothing inherently wrong with having a schedule – most of us fall into one naturally without even trying. The focus herein is on some of the components of schedules that you’re promoting that can actually have a deleterious effect on babies’ and mothers’ health and well-being.
There is no debate from me that babies need sleep – it’s why they sleep an average of 20 hours a day in the beginning (though this is highly variable). I know this is where many of you will come out swinging because there are many articles out there touting the ill-effects of sleep problems, including night waking, and how things like offering comfort only hurt the child with respect to sleep (e.g.). Now, this is typically in reference to advocating for crying-it-out at night and working towards getting babies to sleep through the night early, despite the fact that as humans we are not biologically predisposed to that (for a review of mammalian feeding patterns and how it affects sleep, see Bed-sharing and Co-Sleeping: Research Overview by Dr. Helen Ball).
In fact, night wakings have never been a part of the Diagnostic and Statistical Manual of Mental Health Disorders under Sleep Disorders because, while they may inconvenience parents, they simply aren’t real “problems”, particularly in infancy. But what of the research linking things like night wakings to behavioural problems? Let me say this: Third Variable Problem. In all of this research, parents who report “sleep problems” also tend to report negative affect surrounding their child (which improves with sleep training). In contrast, in non-referred parents (i.e., those who have not sought help for their children’s sleep and do not see it as a problem), positive mother-infant interactions and dyads are related to greater night wakings, yet the night wakings are not deemed problematic and there are no behavioural repercussions associated with them. In short, the evidence surrounding the notion of “sleep problems” in infancy is based solely on parental-report of problems and seems driven by the unrealistic and non-biological expectations placed on babies (and thus mothers who are expected to return to work early, etc., but that’s a topic for another day). But some of your programs also dictate scheduled sleep with naps and night sleeps lasting a certain amount of time, regardless of whether or not your child is still sleeping.
Let me start by asking you – how do you feel if you’re not tired and are forced to lie in bed (usually alone)? Do you get restless and find it even harder to fall asleep? And how about when that alarm goes off to wake you up and you’re very clearly not ready to get up? Tired and groggy for most of the day (or at least until you’ve had your morning cup of coffee)? Even if you go to bed at a “reasonable” hour, if you can’t fall asleep right away because you’re not tired, getting up 8 hours later still sucks because you’ve probably only slept 5-6 hours. Guess what? The same thing applies to babies. Forcing a baby to stay awake when they’re tired or go to sleep when they aren’t is detrimental to babies and a hurt a parent’s relationship as they can end up with a fussy, crying infant. I’ve covered the research before (see Baby Expectations) but infants’ sleep-wake cycles take a while to develop and you do them no favours by trying to rush this. In fact, there is some early evidence that doing this could actually put a baby a risk for SIDS. In one study, only brief periods of sleep disruption were given to infants aged 7 to 18 weeks and cardiac effects were measured. The authors found that by simply delaying sleep 2 hours just once, infants’ cardiac (heart) responses during sleep were altered in ways that could be related to SIDS. A second review examined the evidence for a link between disruption in sleep and SIDS and while there has been no research on a causal relationship, there is work demonstrating that “abnormal” sleep disruption (i.e., not natural wakings) decreases an infant’s arousal ability which has been shown in several studies to be related to SIDS. Therefore, you should be quite careful to suggest that parents rouse their children at a specified time, or that parents should keep their infants’ awake until a certain time – whether that time is dictated by the clock or some other means. I don’t believe that parents are aware that you may be playing with their babies’ lives.
For some reason, the antiquated notion of feeding a baby every 3-4 hours remains in favour for many of you, despite the fact that it’s no longer a recommended practice by medical professionals or lactation consultants. The reason this practice fell out of favour was that it was found to have deleterious effects on the breastfeeding relationship and to the baby’s health.
The effects on baby are well-documented. First, there is the effect on weight gain with infants fed on-cue gaining significantly more weight than infants fed on a schedule. One such study examined weight gain in the first week of life in a very large cohort over a week’s hospital stay post-birth. Three groups were considered: 4-hour feeds, 3-hour feeds, and on-cue feeding and made comparisons for small, medium, and heavy babies in order to account for the natural differences that would occur. The findings? As stated in the article,“The rate of gain is unquestionably greater with the self demand babies” (p. 99). In many cases, the self demand babies were more than doubling the gain of the 4-hour scheduled babies and sometimes even doubling the gain of the 3-hour scheduled babies as well. A second Japanese study found that cue feeding was associated with lower weight loss post-birth relative to infants fed on a schedule. However, there is a study that has been cited before suggesting no difference between scheduled feeds and cue feeds. In this study, no differences in growth from birth to 6 months was found between the two feeding groups, but in both groups, the dominant form of feeding was via formula which has a very different composition than human breastmilk and thus should not be used to form any basis of advice for breastfeeding. An infant’s health is also affected by feeding schedules via a reduction in meconium passing as well as higher bilirubin levels, the by-product that results in jaundice. This means that infants who are given a scheduled feeding are more likely to develop jaundice than those who do not.
The effects of scheduled feeds extend to the entire breastfeeding dyad between mothers and their infants, which can have more global effects if mom is forced to end that relationship early, meaning her child doesn’t get the immense benefits associated with breastfeeding (see Why Is Saving Babies’ Lives Not Enough?). In Norway, certain practices were instituted in the early 1970s in order to facilitate greater breastfeeding rates, of those were the use of on-cue feeding, as opposed to scheduled feeds, and this, along with other practices, did lead to an increase in breastfeeding rates by the early 1980s. The aforementioned Japanese study found that on-cue breastfeeding led to infants receiving more breast milk on days 3 and 5. Even when scheduled feeds were the norm, researchers realized the direct link between the number of feeds and a woman’s milk production. Back in 1961, an article was published with data on how increasing the number of feeds during the day resulted in a parallel increase in milk supply for women, though it took 48 hours before the increase was noticed. None of this even addresses the issues for babies on a growth spurt who typically require extra nourishment in order for their bodies to grow properly.
More generally, people have researched the high prevalence of breastfeeding problems found in industrialized and developed cultures and found that the common denominator is that we promote, what one researcher called it, nonbiological breastfeeding patterns. The scheduling of feeds and reduction in night-time feeds do not match with what humans are biologically predisposed to require and thus there is little surprise that women’s milk productions suffer as a result. Another review on breastfeeding concluded that many of the problems women face in developed nations with respect to breastfeeding stem from the arbitrary rules placed on breastfeeding, such as scheduled feeds. The authors of the review argue that research shows that breastfeeding works best when there are no prescriptive practices in place for it. In line with this, another study found that a mother’s ability to be flexible in her feeds and thus feed when the infant needs it – on-cue, not on a schedule – was related to breastfeeding success, both shorter and long-term.
In sum, scheduled feeds went out of practice for a reason—namely, they can harm baby and have been consistently associated with problems breastfeeding, something we know to be a problem in industrialized societies. The only reason left for them is somehow to convenience the mother, but if she ends up unable to breastfeed as a result, how convenient was it?
There is nothing wrong with a generalized routine. Having a bedtime routine where you bathe and read to your infant prior to feeding them for sleep is harmless. Knowing how your day will generally go is harmless. But when parents start trying to dictate their days down to the hours, regardless of whether this was “guided by baby” or set up by someone else, we start to see problems, and it should be no surprise – babies aren’t meetings or appointments, they’re people. Especially during the first few months, a baby is constantly changing and with it, his or her needs. Trying to force your child to eat and sleep at particular times basically ignores their individual differences because, really, no two babies are the same. We naturally fall into routines, so what on earth would make someone feel the need to “create” one? Does that not take away from the fun and joy of time spent with your newborn? Why not promote parents listening to their little one in order to learn about this little person they’ve brought into the world?
I’m nearly the end of our series here, but I have one more lesson for you which will cover the idea of the external womb and how it facilitates development. As many of you seem to write as if a baby were a full-fledged adult in need of rules and regulations, you might need some information on the biology behind infant development.
More from Educating the Experts:
 Joshi P, Bogen K. Nonstandard schedules and young children’s behavioural outcomes among working low-income families. Journal of Marriage and Family 2007; 69: 139-156.
 Barnett RC, Gareis KC. Shift work, parenting behaviors, and children’s socioemotional well-being: a within-family study. Journal of Family Issues 2007; 28: 727-748.
 Boutot EA. Developing schedules for improved behavior and independence. In EA Boutot & M Tincani (Eds.) Autism Encyclopedia: The Complete Guide to Autism Spectrum Disorders (pp. 149-155). Waco, TX: Prufrock Press, 2009.
 Fuligni AS, Howes C, Huang Y, Hong SS, Lara-Cinisomo S. Activity settings and daily routines in preschool classrooms: diverse experiences in early learning settings for low-income children. Early Childhood Research Quarterly 2011; doi: 10.1016/j.ecresq.2011.10.001.
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 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders – 4th Edition, Text Revision. Washington, DC: Author, 2000.
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